The effect of spreader grafts on nasal dorsal width in patients with nasal valve insufficiency

Casual Observers' Perception on the Aesthetics of the Butterfly Graft

OBJECTIVE

The butterfly graft is an effective technique for improving the internal nasal valve, however, there is hesitancy among surgeons due to possible aesthetic changes. This study aims to determine if average observers rated the post-operative appearance of the butterfly graft negatively.

METHODS

An online survey was distributed by social media to non-medical observers in which they rated either the pre-operative or post-operative appearance of 22 patients' noses (11 butterfly graft, 11 spreader graft). A heat map was used to determine if the supratip region was rated as the least aesthetically appealing. Post-operative ratings and heat maps of the butterfly graft patients were compared to pre-operative ratings as well as ratings of the spreader graft group.

RESULTS

226 observers responded. There was no difference in the pre-operative and post-operative rating of the butterfly graft group (58.27 vs. 58.00, p = 0.88) or the number of supratip regions selected as least attractive (165 vs. 169, p = 0.60). Similarly, there was no difference in post-operative ratings between the butterfly graft group and spreader graft group (58.00 vs. 58.21, p = 0.63) or in selection of the supratip as the least attractive region (169 vs. 172, p = 0.74).

CONCLUSION

The butterfly graft did not negatively affect observers' opinion of patients' noses.

LEVEL OF EVIDENCE

3 Laryngoscope, 133:2578-2583, 2023.

Complications Associated with Spreader Grafts and Spreader Flaps: A Systematic Review

BACKGROUND AND PURPOSE

Spreader grafts and spreader flaps are one of the most common techniques utilized in rhinoplasty surgeries. The aim of this study was to determine the complications, satisfaction, and revision rates associated with spreader grafts and spreader flaps and to compare these two modalities.

MATERIALS AND METHODS

PRISMA guidelines were followed for conducting this systematic review. The authors searched the literature systematically for pertinent materials in PubMed/Medline and Google Scholar. Inclusion criteria of this search included: randomized and non-randomized clinical trials, cohorts, and case series with more than 5 participants on rhinoplasty using spreader grafts or spreader flaps with detailed report either on complications, revision, and satisfaction rates. Furthermore, exclusion criteria included: any cadaveric or non-human study, case reports, technical notes, and review articles.

RESULTS

The initial literature search yielded a total of 193 studies. Following screening each paper and implementing the inclusion and exclusion criteria, 40 articles were chosen. In the spreader graft group, from 21 studies reporting complications, 6 of them reported no complication. The most common complications were nasal obstruction, inverted V deformity and open roof deformity, deviation, and infection. In the spreader flap group, from 6 studies reporting any existing complications, 1 reported no complications. Five other studies reported some degree of complications. In terms of revision rate, 10 patients (0.62%) underwent revision surgery after spreader graft placement, while only 2 patients (0.35%) revised surgically in the spreader flap group.

CONCLUSION

These two methods seem to have no significant difference in terms of complication rates, and both are recommended as a choice in middle vault reconstruction when each of their clinical use is indicated.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Narrowing and Operated Appearance of the Middle Nasal Third after Hump Resection without Middle Vault Reconstruction

BACKGROUND

Little is known about the incidence of narrowing and an operated appearance of the dorsum after hump resections if the dorsum is not reconstructed with spreader grafts or spreader flaps.

METHODS

Patients who had undergone a composite hump resection (n = 22) or a component hump resection (n = 25) were interviewed and photographed with a minimum follow-up of 12 months. Four expert rhinoplasty surgeons and four laypersons rated the appearance of the middle third of the dorsum on the preoperative and postoperative en face photographs. The quartile of the most surgical appearing outcomes was analyzed regarding potentially preventive surgical maneuvers.

RESULTS

No patient was dissatisfied with the frontal view of the nose. Agreement between expert and lay raters (Kendall's coefficient of concordance) was 0.51 (p < 0.01) and 0.34 (p = 0.06) for appearance and 0.55 (p < 0.01) and 0.46 (p < 0.01) for width, respectively. Expert raters found that a surgical appearance of the dorsum had both increased and decreased after surgery, with an average increase of 0.27 ± 1.05 and 0.21 ± 1.18 points on a five-point Likert scale for composite and component resection, respectively. Pearson correlation between the degree of dorsal lowering and surgical appearance on the anterior view was 0.31 (p = 0.026). Reconstruction of the middle third could potentially have improved the outcome in 15 percent of the patients.

CONCLUSIONS

Lowering of the dorsum without middle vault reconstruction on average increased an operated appearance to a small degree that was not noted by the patients. This effect was similar for composite and component hump resections.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Challenging Rhinoplasty for the Cleft Lip and Palate Patient

Cleft lip and palate patients represent one of the most challenging groups of patients for septorhinoplasty, presenting as a complex surgical obstacle for even the most seasoned surgeons. These individuals have undergone several surgeries throughout their lives, resulting in a considerable amount of scar tissue, significant asymmetries and structural deficits. Key factors in successfully treating cleft lip and palate patients are the reconstruction of the absent/asymmetric cartilages and the replacement of bony structures. The use of autogenous rib cartilage allows the surgeon to create various grafts as well as fortify the soft tissue to resist persistent soft tissue deformities.

Analysis of Patient-Perceived Nasal Appearance Evaluations Following Functional Septorhinoplasty With Spreader Graft Placement

Importance

Spreader grafts have been shown to improve nasal airway obstruction in patients with nasal valve dysfunction; however, their use has been limited by concerns over their aesthetic penalty of widening the nasal dorsum.

Objective

To evaluate the association of functional septorhinoplasty (FSRP) using spreader graft placement with patient satisfaction with nasal appearance postoperatively.

Design, Setting, and Participants

This prospective cohort study was conducted in a university-based tertiary care medical center. All participants were patients undergoing FSRP for the treatment of nasal obstruction who had spreader grafts placed between June 2016 and May 2018.

Exposures

The Nasal Obstruction Symptom Evaluation (NOSE) scale and the FACE-Q Satisfaction With Nose, FACE-Q Satisfaction With Nostrils, and FACE-Q Social Functioning scales were administered to patients preoperatively and at 2, 4, 6, and 12 months postoperatively. Patient demographics, nasal history, and outcomes were analyzed.

Main Outcomes and Measures

Comparison of preoperative and postoperative NOSE and FACE-Q scores.

Results

A total of 154 patients (72 male [46.8%]) with mean (SD) age of 36.8 (15.4) years underwent FSRP with spreader graft placement. Mean (SD) last follow-up was 5.8 (4.1) months postoperatively (range, 2-12 months). Fifty-seven patients had 6 months follow-up, and 42 patients had at least 12 months of follow-up. At time of last follow-up, mean (SD) NOSE and FACE-Q Satisfaction With Nose, Satisfaction With Nostrils, and Social Functioning scores significantly improved from 62.7 (20.7) to 22.8 (21.0) (P < .001), 54.7 (22.2) to 76.2 (25.1) (P < .001), 59.4 (27.9) to 83.6 (24.8) (P < .001), and 73.6 (21.8) to 81.7 (21.9) (P < .001), respectively. When separated into those with only spreader grafts (n = 89) and those with spreader grafts plus other graft types (n = 65), there was no significant difference between score improvements in the 2 groups. There were no significant differences in final nasal appearance scores between patients undergoing functional vs dual functional and cosmetic FSRP.

Conclusions and Relevance

Despite concerns that placement of spreader grafts for the treatment of nasal obstruction due to nasal valve dysfunction during FSRP may have a negative impact on nasal aesthetics, this study shows that both nasal obstruction and patient satisfaction with their nasal appearance were significantly improved following surgery.

Level of Evidence

3.

Outcome of rhinoplasty in patients undergoing autospreader flaps without notable dorsal hump reduction: A clinical trial

BACKGROUND

Reconstruction of the nasal midvault is an important component of successful rhinoplasty outcomes. Use of the autospreader flap is a beneficial technique for preserving the middle vault. In the present study, we evaluated the esthetic and functional outcomes of this technique in patients without notable dorsal hump reduction.

METHODOLOGY

A nonrandomized clinical trial was performed from December 2017 to April 2018 with a minimum follow-up time of 6 months. From among patients seeking rhinoplasty, 38 were eligible for inclusion in the study. The autospreader flap was used to recreate the middle vault in patients undergoing open rhinoplasty, with up to 2 mm bony and cartilaginous dorsal hump removal. Preoperative and postoperative standard photographs were obtained. Assessment of patients was based on Rhinoplasty Outcome Evaluation (ROE) and Nasal Obstruction Symptom Evaluation Scale (NOSE) scores. Objective assessment included quantitative analysis of anthropometric angles, mean dorsal width, nasal length, and projection which was performed on standard pre- and postoperative photos.

RESULTS

Overall, the patients had statistically significant improvement in their postoperative NOSE scores (9 vs. 6.92, p = 0.0001). The majority of patients were satisfied with the postoperative appearance of their noses. The mean nasal dorsal width (NDW) decreased postoperatively (43% vs. 36%). No difference was found between the mean height of the nose and projection pre- and postoperatively. There was a significant postoperative increase in the nasolabial angle and reduction in nasal length.

CONCLUSIONS

The autospreader flap is an effective technique for preservation and restoration of the middle vault and dorsal esthetic line in cases of less than 2 mm dorsal hump reduction. Nasal function can be improved while achieving good cosmetic outcomes.

The Effect of Spreader Graft and Mattress Suture Technique on Rhinoplasty in Patients With Nasal Hump Smaller Than 3 mm

INTRODUCTION

Rhinoplasty is a common plastic surgery that potentially has some complications such as postoperative deformities and breathing problems. A humpy nose is among the main reasons for rhinoplasty. Nasal valve (the narrowest part of the nasal airway) collapse may be occurred after nasal hump removal. Spreader graft is essential after more than 3 mm nasal hump removal. But the value of this graft is unknown for patients with nasal hump smaller than 3 mm. Mattress suture is another technique for widening the nasal valve angle. This study compares the effects of spreader graft and mattress suture technique on postoperative deformity and nasal valve patency in patients with nasal hump smaller than 3 mm as compared with control group (no graft and suture).

METHODS

In this clinical trial study 210 patients who underwent rhinoplasty with 2 different techniques involved. Their postoperative deformity and nasal valve patency were evaluated by subjective (questionnaire and digital photography) method before and after rhinoplasty during 6 months follow-up.

RESULTS

Statistically, nasal obstruction had no significant difference before and after rhinoplasty and no significant difference was observed between spreader graft and mattress sutures (P > 0.05), but significantly better results than control group (P < 0.05).

CONCLUSION

In this study the results of nasal valve patency of 2 techniques were similar. Because of several considerations in spreader graft technique such as needing to septoplasty in this technique even in patients without septal deviation that causes longer surgical duration, excessive blood loss, it is recommended to use Mattress suture in patients with nasal hump smaller than 3 mm.

Assessment of Functional Rhinoplasty with Spreader Grafting Using Acoustic Rhinomanometry and Validated Outcome Measurements

BACKGROUND

Rhinoplasty is 1 of the most common aesthetic and reconstructive plastic surgical procedures performed within the United States. Yet, data on functional reconstructive open and closed rhinoplasty procedures with or without spreader graft placement are not definitive as only a few studies have examined both validated measurable objective and subjective outcomes of spreader grafting during rhinoplasty. The aim of this study was to utilize previously validated measures to assess objective, functional outcomes in patients who underwent open and closed rhinoplasty with spreader grafting.

METHODS

We performed a retrospective review of consecutive rhinoplasty patients. Patients with internal nasal valve insufficiency who underwent an open and closed approach rhinoplasty between 2007 and 2016 were studied. The Cottle test and Nasal Obstruction Symptom Evaluation survey was used to assess nasal obstruction. Patient-reported symptoms were recorded. Acoustic rhinometry was performed pre- and postoperatively. Average minimal cross-sectional area of the nose was measured.

RESULTS

One hundred seventy-eight patients were reviewed over a period of 8 years. Thirty-eight patients were included in this study. Of those, 30 patients underwent closed rhinoplasty and 8 open rhinoplasty. Mean age was 36.9 ± 18.4 years. The average cross-sectional area in closed and open rhinoplasty patients increased significantly (P = 0.019). There was a functional improvement in all presented cases using the Nasal Obstruction Symptom Evaluation scale evaluation.

CONCLUSIONS

Closed rhinoplasty with spreader grafting may play a significant role in the treatment of nasal valve collapse. A closed approach rhinoplasty including spreader grafting is a viable option in select cases with objective and validated functional improvement.

Uses of Various Grafting Techniques in External Approach Rhinoplasty: An Overview

The surgeons performing rhinoplasty found Graft selection the greatest challenge. To avoid an immune response the preferred choice thus far for nasal reconstruction would be autograft compared to allograft due to its lower rate of rejection. We have evaluated 30 patients who underwent open rhinoplasty and We used conchal and septal cartilaginous grafts in various forms by the open approach to correct various nasal deformities compared our experience regarding the operative technique, graft availability, indications, and limitations. No bony graft material or synthetic materials were used. Preoperative extensive evaluation of the patient was done in order to determine the type of deformity and the type of graft to be used in order to correct the deformity. Preoperative and postoperative photographs were taken in four basic views: frontal, lateral, lateral-oblique and basal in order to assess the results of the surgery. The study was done on 30 patients (20 male and 10 females) using the external rhinoplasty approach using the septal and conchal cartilages in different forms. Autologous septal cartilage was used in most of the patients (25 out of 30) and conchal cartilage was used in 5 patients. Multiple grafting techniques were used in some patients. Three patients had traumatic etiology. Columellar strut graft along with TIG technique was used in 16 patients, spreader graft was used in 8 patients, and septal extension graft was used in 5 patient and shield graft in 1 patient. Septorhinoplasty continues to evolve through various new techniques and modifications with the main goal to improve functional nasal airway and to restore cosmetic harmony to the face. Optimum result is very much dependent on the surgeon's attention to functional, aesthetic, and reconstructive principles and graft selection.

A systematic review of the surgical techniques for the treatment of internal nasal valve collapse: where do we stand?

BACKGROUND

A myriad of interventions have been described to address the restoration or preservation of the internal nasal valve, the narrowest portion of nasal airway.

OBJECTIVE OF REVIEW

To review systematically available knowledge and evidence about management options of the collapse of the internal nasal valve area.

TYPE OF REVIEW

Systematic review.

SEARCH STRATEGY

A MEDLINE, EMBASE, Cochrane Library and CENTRAL database search, followed by extensive hand searching for the identification of relevant studies.

EVALUATION METHOD

Review of all English-language studies addressing the treatment of the internal nasal valve collapse.

RESULTS

Fifty-three studies were eventually identified and systematically reviewed. The majority (50 of 53) of the included articles are graded as level IV evidence and only one randomised trial was identified. The included randomised study reported no significant difference in improvement between the intervention group (autospreader flap) and placebo arms. The majority of the included studies presented in this systematic review provide level IV evidence concerning the optimal approach for cases of nasal valve collapse. Current research is driven more by reports of techniques than patient outcomes.

CONCLUSIONS

Proper evaluation and identification of the cause of the internal nasal valve collapse is paramount prior to selection of the preferred surgical solution. The three-dimensional construction of the nasal valve implies that many pathologies cannot be restored by a single solution. Treatment approaches should be directed at specific involved sites. Present systematic review of the literature revealed that the available evidence is based on low-level studies and focuses more on the description of various surgical techniques rather than on patient-reported outcome measures. Future studies are needed, including homogenous patient groups, comparing different surgical techniques and incorporating patient-reported outcome measures.

A Cadaveric Study Comparing the Efficacy of the Sheen Spreader Graft and the Fulcrum Spreader Graft: Part 1

BACKGROUND

Middle vault collapse is one of the common causes of airway obstruction. Several techniques have been described to alleviate this problem. The Sheen spreader graft is a well-established technique. The fulcrum spreader graft has been in use at the authors' institution for 10 years. No studies currently exist that have compared the efficacy of middle vault reconstruction methods. In this first part of their studies, the authors have compared the efficacy of the Sheen spreader graft technique to the fulcrum spreader graft technique under normal atmospheric conditions.

METHODS

Twenty fresh unemblamed cadavers were used for the study. Outcome variables were cross-sectional area at three points within the nose, minimum cross-sectional area, resistance, volume, and minimum distance. Exposure variables were control, Sheen, and fulcrum. Data were acquired with the aid of an acoustic rhinometer.

RESULTS

Analysis of the data showed that the fulcrum spreader graft technique provided statistically significant outcomes compared with control and the Sheen technique.

CONCLUSION

The fulcrum spreader graft technique may be a more effective technique for middle vault reconstruction compared with the Sheen spreader graft technique.

Spreader flaps for middle vault contour and stabilization

Nasal hump excision is common during septorhinoplasty. Without appropriate restoration of the middle nasal vault, cosmetic and functional problems may ensue. Recently, spreader flaps have become an established alternative to traditional spreader grafts. Typical indications include primary rhinoplasty patients with hump noses, hump/tension noses, and moderately hooked or crooked noses. When suitable patients are selected, spreader flaps and their modifications represent a reliable alternative to the standard spreader graft, and when all of the necessary prerequisites are met, this technique obviates the need for additional cartilage grafting in most cases.

[Flaring spreader flaps and upper lateral advancement. Modified techniques in the reconstruction of the internal nasal valve]

BACKGROUND

A collapse of the internal nasal valve and the formation of an inverted-V deformity represent common findings following dorsal hump removal in rhinoplasty procedures. Spreader grafts are considered as standard both in the prevention and treatment of such undesirable outcomes. The authors introduce modified surgical concepts using flaring spreader flaps and the upper lateral advancement technique to reconstruct the internal nasal valve.

METHODS

After mobilization of the mucosa and separation of the upper lateral cartilages from the septum also their attachments to the nasal bones are released. The cartilages then are rotated as spreader flaps into the area of the internal nasal valve and can be used as a replacement for conventional spreader grafts. By crucial modifications of commonly applied suture techniques both the contour and airway are improved. The upper lateral advancement technique is used in cases of already present inverted-V deformities. The upper lateral cartilages are mobilized in a similar fashion and serve as attachments to usual spreader grafts.

RESULTS

Flaring spreader flaps have been used in 164 patients undergoing primary rhinoplasty procedures for dorsal hump removals, the treatment of tension noses as well as deviated noses. Postoperatively all cases showed an adequate width of the middle nasal vault and pleasant dorsal aesthetic lines. No signs of an inverted-V deformity or a collapse of the internal nasal valve were present. Nasal breathing was considered significantly improved. The upper lateral advancement technique was applied in 9 patients with a present inverted-V deformity after previous rhinoplasties. During the following revision procedures an adequate reconstruction of the middle nasal vault as well as a subjectively improved airway was achieved in all cases.

CONCLUSION

Both flaring spreader flaps and the upper lateral advancement technique represent reliable methods in the reconstruction of the internal nasal valve and treatment of inverted-V deformities. Moreover, flaring spreader flaps can be considered as an appropriate alternative to conventional spreader grafts in patients with only small amounts of cartilage available.

Assessment of rhinoplasty techniques by overlay of before-and-after 3D images

This article describes the equipment and software used to create facial 3D imaging and discusses the validation and reliability of the objective assessments done using this equipment. By overlaying preoperative and postoperative 3D images, it is possible to assess the surgical changes in 3D. Methods are described to assess the 3D changes from the rhinoplasty techniques of nasal dorsal augmentation, increasing tip projection, narrowing the nose, and nasal lengthening.

The value of spreader grafts in rhinoplasty: a critical review

The value of spreader grafts in rhinoplasty cannot be underestimated. Various studies have demonstrated that they play a valuable role in the restoration of nasal dorsum aesthetics, provide support for the nasal valve and maintain the straightened position of the corrected deviated cartilaginous septal dorsum. However, there is still controversy on the extent of its value in nasal patency. This study reviews the literature and describes the values and limitations of spreader grafts in rhinoplasty and the alternatives to classic spreader grafts.

Endonasal repositioning of the upper lateral cartilage and the internal nasal valve

OBJECTIVES

Collapse of the upper lateral cartilage (ULC) is associated with narrowing of the internal nasal valve (INV). The goal of this article is to describe a novel procedure that repositions the ULC, opening the INV, without implants, grafts, or permanent sutures.

METHODS

Before-and-after digital photographs of patients with ULC and INV collapse who underwent endonasal ULC repositioning were analyzed. The surgical procedure consists of an intercartilaginous incision and the creation of a surface that permits scarification upon cartilage reapproximation. Precise placement of a support apparatus permits the ULC to heal into a position in direct contact with the lower lateral cartilage,thus dilating the INV. The percentage of collapse of the ULC (PCULC), determined by ULC shape measurements made with computer-aided design software, was compared on before-and-after photographs by use of Student's t-test (paired).

RESULTS

The study included 52 patients (79 procedures) followed for 1 to 18 months after surgery in the period 2007 to 2009. There were no complications or revision surgeries. The preoperative mean PCULC was 58.6%. The postoperative mean PCULC was 5.7% (p < 0.0001).

CONCLUSIONS

Repair of the INV via ULC repositioning is a simple, relatively safe procedure that produces a statistically significant improvement in the PCULC. The functional change at the INV may be inferred from the ULC shape, but further prospective clinical studies are required.